AC FFC Tidbit of the Week for May 21, 2023: Antipsychotics and Dementia–When the Risks Outweigh the Benefits

People with dementia can sometimes become agitated, especially when they are in unfamiliar surroundings, with unfamiliar people, and feeling powerless…like when they’re in the hospital.

Sometimes, the first course of action to manage someone who is highly agitated in an acute care setting is to give them an antipsychotic medication. But giving antipsychotics to older adults with dementia carries significant risks, including an increased risk of death.

Here are answers to three common questions about the use of antipsychotics:

For what conditions are antipsychotics approved for use by the Food and Drug Administration?

Bipolar disorder (not an exclusion from denominator), schizophrenia, adjunct to antidepressants for major depressive disorder (aripiprazole), Tourette’s syndrome (conventional antipsychotics only), and Huntington’s disease.

What risks are associated with taking an antipsychotic?

Falls and fracture; sedation; delirium; functional decline; extrapyramidal symptoms (Parkinsonism, dyskinesias); anticholinergic side effects (orthostatis, constipation, blurry vision, etc.); hyperglycemia; hyperlipidemia; drug interaction (40% chance); pneumonia; cardiovascular risks; and death (mortality is highest in first 30-40 days).

What are some non-pharmacological alternatives to antipsychotics?

  • Rule out medical cause (delirium screening, vigilant medical care)
  • Address unmet needs (are they in pain? thirsty? need to use the toilet?)
  • Implement effective communication strategies
  • Keep activities and caregivers consistent and routine
  • Modify the environment as needed (minimize noise in room, temperature, etc.)
  • Maximize sensory input (glasses, hearing aids, plenty of light)
  • Involve the person in functional & physical activities
  • Incorporate personal preferences as much as possible

These non-pharmacological approaches require critical thinking and teamwork. When they work, they help the patient avoid the adverse effects of antipsychotic medication, and can the caregiving team may find these approaches more fulfilling too. Put yourself in the patient’s shoes to better understand what they are feeling (and fearing!), and try the approaches above to help calm a person who is agitated.

Finally, here’s a helpful overview developed by the American Geriatrics Society and Consumer Reports that you may also want to share with a patient’s family members:

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